Very effective, with little to remember. Copper T 380A lasts for 10 years.

1. Copper IUD Copper IUD • About the IUD: • Small flexible plastic frame with copper sleeves and/or wire. • Give client a sample IUD to hold. • Works mainly by stopping sperm and egg from meeting. • Most women can use IUDs, including women who have never been pregnant. • Small device that fits inside the womb • Very effective • Very effective, with little to remember. • Copper T 380A lasts for 10 years. • For older women: should be removed 1 year after last menstrual period (menopause). • Can soon become pregnant when IUD taken out. • Keeps working up to 10 years, depending on type • We can remove it for you whenever you want • Check for concerns, rumours: “What have you heard about the IUD?” (See Appendix 10 on myths about contraception.) • Explain common myths: • IUD does not leave the womb and move around inside the body. • IUD does not get in the way during intercourse, although sometimes the man may feel the strings. • IUD does not rust inside the body, even after many years. • Very safe • Might increase menstrual bleeding or cramps • Side-effects usually get better after first 3 months (see page IUD3). • No protection against STIs or HIV/AIDS • For STI/HIV/AIDS protection, also use condoms. Next Move: “Do you want to know more about the IUD, or talk about a different method?” If client wants to know more about the IUD, go to next page. To discuss another method, go to a new method tab or to Choosing Method tab. IUD1 IUD

2. Who can and cannot use the IUD Most women can safely use the IUD • But usually cannot use IUD if : • Unusual vaginal bleeding recently • Gave birth recently (more than 2 days ago) • May be pregnant • At high risk for STIs • Infection or problem in female organs

3. Copper IUD Who can and cannot use the IUD Most women can safely use the IUD. But usually cannot use IUD if: “We can find out if the IUD is safe for you. Usually, women with any of these conditions should delay insertion or use another method.” • If in any doubt, use pregnancy checklist in Appendix 1 or perform pregnancy test. • May be pregnant • IUD should not be inserted between 48 hours and 4 weeks after childbirth because of expulsion risk. • Gave birth recently (more than 2 days ago) • If at high risk for chlamydia or gonorrhoea infection. • Those at high risk for these STIs include anyone who: • has more than 1 sex partner without always using condoms; • has sex partner who may have sex with others without always using condoms. • At high risk for STIs • Unusual bleeding should be assessed before IUD insertion. • Unusual vaginal bleeding recently • STI or Pelvic Inflammatory Disease (PID): • Treat PID, chlamydia, gonorrhoea or purulent cervicitis BEFORE inserting IUD. Offer to treat partnertoo. • Can insert IUD if client has genital ulcer disease or vaginitis (bacterial vaginosis, trichomonas vaginalis), but check risk for chlamydia or gonorrhoea. Treat infections. • HIV or AIDS: • If client has HIV, can insert IUD. • If client has AIDS, do not insert IUD. But if client is being treated with antiretroviral drugs and is healthy, can insert IUD. • Infection after childbirth or abortion: • Any infections should be fully treated before IUD insertion. • Cancer in female organs or pelvic tuberculosis (TB): • Do not insert IUD if known cervical, endometrial or ovarian cancer; benign or malignant trophoblast disease; pelvic TB. • Infection or problem in female organs Next Move: Client able to use the IUD:go to next page. Client unable to use the IUD: help her choose another method. IUD2 2

4. Possible side-effects If you choose this method, you may have some side-effects. They are not usually signs of illness. Other common side-effects: After insertion: • Longer and heavier periods • Some cramps for several days • Bleeding or spotting between periods • Some spotting for a few weeks • More cramps or pain during periods May get less after a few months How would you feel about these side-effects?

5. Copper IUD Possible side-effects • “It can take time for the body to adjust.” • Different people have different reactions to methods. If you choose this method, you may have some side-effects.They are not usually signs of illness. • Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • Discuss any rumours or concerns.(See Appendix 10). • “Please come back any time you want help or have questions.” • “It is okay to switch methods any time.” • For dealing with side-effects, see Returning Client tab. • After insertion: • Some cramps for several days • Some spotting for a few weeks • For cramps after insertion, can take aspirin, paracetamol, or ibuprofen. • Other common side-effects: • Longer and heavier periods • Bleeding or spotting between periods • More cramps or pain during periods • May get less after a few months • For longer, heavier and more painful periods, she can take ibuprofen or a similar medication (NOT aspirin). • Cramps and bleeding usually get less after 3 to 6 months. Next Move: Does client understand side-effects? Is she happy to use method? If so, go to next page. If not, discuss further or consider other methods. IUD3

6. What will happen when you get your IUD Steps: Pelvic examination Cleaning the vagina and cervix Placing IUD in the womb through the cervix    • May hurt at insertion • Please tell us if it hurts • Rest as long as you like afterwards • May have cramps for severaldays after insertion Afterwards: you can check your IUD from time to time Are you ready to choose this method? What questions do you have?

7. Copper IUD What will happen when you get your IUD Steps: Pelvic examination Cleaning the vagina and cervix Placing IUD in the womb through the cervix • Ask if she has any questions or concerns. • Explain who will do the procedure. • No anaesthesia needed. Woman stays awake.   • If it is her first pelvic exam, explain exam, including position during exam. Let client hold a speculum. Explain its use.  • Done slowly and gently. • Show sample IUD with arms folded in inserter. • May hurt at insertion • Please tell us if it hurts • Rest as long as you like afterwards • May have cramps for severaldays after insertion • Any immediate pain usually lasts 30 minutes at most. • When to check: • Once a week in first month. • After a menstrual period from time to time. • How to check: • Wash hands, sit in squatting position, insert a finger into vagina and feel for IUD strings at cervix. Don’t pull on the strings. • If unable to feel strings, or strings feel longer or shorter, she should come back to the clinic. IUD may have been expelled, and she may need emergency contraception. Afterwards:you can check your IUD from time to time Next Move: Does client understand IUD insertion procedure? Is she ready to choose method? If she has decided to use method, go to next page. If not, discuss further or consider other methods. IUD4

8. You may be able to get your IUD now • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant • IUD can be inserted in first 2 days after you give birth Would you like to get your IUD now?

9. Copper IUD You may be able to get your IUD now • If menstrual bleeding started in last 12 days, can insert IUD now. • If menstrual bleeding started more than 12 days ago, can insert IUD now if reasonably certain she is not pregnant (use pregnancy checklist in Appendix 1).No need to wait for next menstrual period. • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant • Insertion after childbirth: • Can insert within 48 hours after birth. Special training needed. • Can also insert after 4 weeks after birth. Must be reasonably certain she is not pregnant. • Between 48 hours and 4 weeks after birth, delay insertion. Offer condoms or another method if she is not fully breastfeeding. • IUD can be inserted in first 2 days after you give birth • After miscarriage or abortion: • Can insert immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. • If switching from another method: • If she has been using a reliable method correctly (including LAM) or has had no sex since last period, you can insert the IUD now, not only during menstruation. • If infection: • Can insert after infection is fully treated and cured. Offer condoms or another method to use in the meantime. Next Move: Is she ready to get her IUD now? If she can get her IUD now, prepare for insertion or arrange appointment for insertion as soon as possible. If she must wait, offer condoms or another method. IUD5

10. What to remember • Your kind of IUD: • When to have IUD taken out: See a nurse or doctor if: • Missed a menstrual period, or think you may be pregnant • Bleeding changes and cramps are common. Come back if they bother you. • Could have an STI or HIV/AIDS • Come back for a check-up in 3 to 6 weeks or after next menstrual period • IUD strings seem to have changed length or are missing • Bad pain in lower abdomen Anything else I can repeat or explain? Any other questions?

11. Copper IUD What to remember • Give client an information card or copy of client’s page and explain. Tell her to keep card in a safe place. • Copper T 380A lasts for 10 years. • For older women, IUD should be left in place until 1 year after last menstrual period (menopause) for full protection from pregnancy. • Your kind of IUD • When to have IUD taken out • Bleeding changes and cramps are common. Come back if they bother you. • Make appointment to check IUD is still in place and no infection. • Encourage her to come back any time to discuss problems or have the IUD removed. • Come back for a check-up in 3 to 6 weeks or after next menstrual period • See a nurse or doctor if: • — Missed a menstrual period, or think you may be pregnant • — Could have an STI or HIV/AIDS • — IUD strings seem to have changed length or are missing • — Bad pain in lower abdomen • Return Signs: • “These signs mean a doctor or nurse should check if a problem is developing.” • “I want you to know about them and remember them.” • She should tell other health care providers that she has an IUD. Last Moves: “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection!Last, most important message: “Come back any time you have questions or want the IUD removed.” IUD6

12. The Pill • Take a pill every day • Can be very effective • Very safe • Helps reduce menstrual bleeding and cramps • Some women have side-effects at first—not harmful • No protection against STIs or HIV/AIDS Do you want to know more about the pill, or talk about a different method?